Abruptio placentae

Presentation about Abruptio placentae and its various problems

1. Abruptio placentae Dr.Rupa Rajshekar MBBS, MD Specialist in Obg Al Bukariya general hospital 13 November 2011 1 Abruptio placentae - Dr.Rupa

2. Definition Abruptio Placentae is the premature separation of the normally implanted placenta from the uterine wall after the 20 th week of gestation until the 2 nd stage of labor. 13 November 2011 2 Abruptio placentae - Dr.Rupa

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4. Epidemiology 1/3 of all ante-partum bleeding is due to A P Incidence ranging from 1 in 75 to 1 in 225 births AP recurs in 5 to 17% of pregnancies after 1 prior episode Up to 25% after 2 prior episodes 13 November 2011 4 Abruptio placentae - Dr.Rupa

5. Etiology Primary cause of A P is uncertain Several associated conditions identified : Increase in age & parity: 1.3-1.5% Pre- eclamsia : 2.1-4% Chronic hypertension: 1.8-3% Preterm ruptured membranes: 2.4-4.9% Multifetal gestation: 2.1% 13 November 2011 5 Abruptio placentae - Dr.Rupa

6. Etiology Cigarette smoking: 1.4-1.9% Cocaine abuse: NA Prior abruption: 10-25% Uterine leiomyoma : NA Hydromnios : 2% 13 November 2011 Abruptio placentae - Dr.Rupa 6

7. Classification Revealed type: Bleeding is revealed. Concealed type: No obvious bleeding. Mixed type: Combination of 1&2 above. In the concealed type(20%), the hemorrhage is confined within the uterine cavity, detachment of the placenta may be complete, and the complications are often severe. In the revealed type(80%) the blood drains through the cervix, placental detachment is more likely to be incomplete, and the complications are fewer and less severe 13 November 2011 7 Abruptio placentae - Dr.Rupa

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10. Pathophysiology Placental abruption initiated by hge into decidua basalis Haematoma formation In concealed type blood accumulates & seeps into myometrium Couvelaire’s uterus 13 November 2011 10 Abruptio placentae - Dr.Rupa

11. Couvelaire’s uterus Also called as Utero -placental apoplexy First described by Couvelaire in early 1900 Extravasation of blood into uterine musculature & beneath uterine serosa Demonstrated only at laparotomy These myometrial hge interfere with uterine contraction to produce PPH 13 November 2011 Abruptio placentae - Dr.Rupa 11

12. Couvelaire’s uterus 13 November 2011 Abruptio placentae - Dr.Rupa 12

13. Pathophysiology Blood gains access to amniotic fluid through rupture membranes With disrupted placental site there is reduced metabolic exchange Process continues with release Fetal hypoxia of tissue thromboplastin in maternal circulation DIC 13 November 2011 13 Abruptio placentae - Dr.Rupa

14. Complications Maternal: Maternal mortality Hypovolaemic shock Renal failure DIC PPH Rhesus sensitization Complication of massive transfusion 13 November 2011 14 Abruptio placentae - Dr.Rupa

15. Complications Fetal: Fetal death Hypoxic brain injury IUGR Neonatal anemia Congenital malformations (CNS) 13 November 2011 15 Abruptio placentae - Dr.Rupa

16. Signs & symptoms Vaginal bleeding : 78% Uterine tenderness: 66% Back pain: 60% Fetal distress: 22% Hypertonus : 17% Fetal demise: 15% 13 November 2011 Abruptio placentae - Dr.Rupa 16

17. Diagnosis Basis of diagnosis consists of : History & physical examinations Triad of external bleeding through cervical Os, Uterine or back pain and fetal distress should be of high suspicion Defer digital cervical examinations until PP & VP are ruled out Ultrasound – limited value but for large abruptions hypoechoic areas seen underlying placenta 13 November 2011 17 Abruptio placentae - Dr.Rupa

18. Ultrasound 13 November 2011 Abruptio placentae - Dr.Rupa 18

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21. Laboratory tests Complete blood cell count Blood type & screen Urine analysis, Liver function tests Renal function tests Prothrombin time/ aPTT Fibrinogen levels FDP – Fibrin degradation products 13 November 2011 21 Abruptio placentae - Dr.Rupa

22. Classification of A P depending on history & investigations Grade O : Asymptomatic –incidental finding of retro- placental clot Grade 1 : Vaginal bleeding, no maternal or fetal compromise – uterine tenderness present Grade 2 : Fetal distress No evidence of maternal shock Vaginal bleeding may not be present Grade 3 : Maternal shock & fetal demise present Marked uterine tetany & tenderness Vaginal bleeding may not be present 13 November 2011 22 Abruptio placentae - Dr.Rupa

23. Management Depends on condition of mother & gestational age of fetus: Large bore IV access obtained Fluid resuscitation Foley’s catheter Maternal vitals close monitoring Continuous FHR monitoring Rh D immunoglobulin administered to Rh (-) patients 13 November 2011 23 Abruptio placentae - Dr.Rupa

24. Management Term gestation, hemodynamically stable: Plan for vaginal delivery with CS for usual indications Follow serial hematocrit & coagulation studies Continuous fetal monitoring Term gestation, hemodynamic instability: Aggressive fluid resuscitation Transfuse packed RBC, fresh frozen plasma & platelets as needed Maintain Fibrinogen level > 150 mg/deciliter, hematocrit > 25% & platelet over 60000/ μ L Urgent CS unless vaginal delivery is imminent 13 November 2011 24 Abruptio placentae - Dr.Rupa

25. Management Preterm gestation hemodynamically stable: In absence of labor, preterm AP should be followed with serial USG for fetal growth Steroids should be given to promote fetal lung maturity If maternal instability or fetal distress arises delivery should be performed, if not labor can be induced at term Preterm gestation hemodynamically unstable: Delivery should be performed after appropriate resuscitation 13 November 2011 25 Abruptio placentae - Dr.Rupa

26. Conclusion Abruptio Placentae is an important cause of fetal and maternal morbidity and mortality. The etiology is poorly understood , various management options are however available. The principle of initial assessment of the patients condition and subsequent planned management aimed at resuscitation and prolongation of pregnancy if possible or immediate delivery either for fetal or maternal indications. 13 November 2011 26 Abruptio placentae - Dr.Rupa

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